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4. Mood Disorders > Geriatric Depression > Flashcards

Geriatric Depression Flashcards

1
Q

what is the community prevalence rate of late life depression

A

11.2%

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2
Q

list components of a complete assessment for late life depression

A

A complete assessment for late-life depression requires:

Reviewing the diagnostic criteria for late-life depression

Reviewing current medications, allergies, and substance use

Reviewing current stresses and life situation

Assessing level of functioning/disability

Considering support system, family situation, and personal strengths

Cognitive testing

Neurological exam and physical exam if applicable

Ordering laboratory investigations to identify any medical problems that could contribute to or mimic depressive symptoms (e.g. - hypothyroidism, anemia)

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3
Q

what population makes up the bulk of the increased risk of completed suicides in older adults with depression

A

older white males

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4
Q

name a scale that can be used to assess late life depression

A

Geriatric Depression Scale (GDS)

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5
Q

what is the vascular depression hypothesis

A

cerebrovascular disease predisposes, precipitates, or perpetuates depressive symptoms in late life

vascular disease is thought to affect FRONTO-STRIATAL circuitry –> resulting in executive dysfunction, depression and cognitive impairment

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6
Q

what is the prevalence of delirium superimposed on dementia

A

ranges from 22-89% of hospitalized and community populations aged 65+ with dementia

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7
Q

what are the cardinal features of depression, dementia and delirium

A

dementia–> memory loss

delirium–> inattention and confusion

depression–> sadness, anhedonia

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8
Q

compare the onset of depression, dementia and delirium

A

dementia–> insidious

delirium–> acute or subacute

depression–> slow

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9
Q

compare the course of depression, dementia and delirium

A

dementia–> chronic, progressive (but stable over the course of the day)

delirium–> fluctuating, often worse at night

depression–> single or recurrent episodes, can be chronic

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10
Q

compare the duration of depression, dementia and delirium

A

dementia–> months to years

delirium–> hours to months

depression–> weeks to years

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11
Q

compare the LOC in depression, dementia and delirium

A

dementia–> normal in early stages

delirium–> impaired, fluctuates

depression–> normal

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12
Q

compare attention in depression, dementia and delirium

A

dementia–> normal (except in late stages)

delirium–> poor

depression–> may be impaired

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13
Q

compare presence of hallucinations in depression, dementia and delirium

A

dementia–> often absent

delirium–> fleeting, non-systematizes

depression–> not usually (inly if psychotic depression)

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14
Q

compare EEG findings in depression, dementia and delirium

A

dementia–> normal or mild diffuse slowing

delirium–> moderate to severe background slowing

depression–> usually normal

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15
Q

how well do ADs work to treat depression in dementia

A

not well–> guidelines do not suggest routine treatment of depression and anxiety with antidepressants

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16
Q

what types of psychotherapy have strong evidence in late life depression

A

CBT

problem solving therapy

IPT

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17
Q

list 4 ADs that are relatively safe in the elderly

A

buproprion

mirtazapine

moclobemide

venlafaxine

*lower anticholinergic effect compared to older ADs
–minimizes delirium risk and cognitive impairment risk

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18
Q

in clinical studies, which ADs have been shown to be the most efficacious in the treatment of late life depression

A

MAOIs and TCAs

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19
Q

which two TCAs have the lowest anticholinergic burden

A

nortriptyline

desipramine

*most tolerated of the TCAs

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20
Q

what should be the “first step” in pharmacologic treatment of late life depression

A

monotherapy with one of the following (or in sequence):
duloxetine
mirtazapine
sertraline
venlafaxine
vortioxetine
citalopram
desvenlafaxine
escitalopram

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21
Q

what should be the “second step” in pharmacologic treatment of late life depression (if multiple first step treatments are not effective or not indicated)

A

switch to:
nortiptyline
fluoxetine
moclobemide
paroxetine
phenelzine
quetiapine
trazodone
buproprion

or combine with:
ablify
methylphenidate
lithium

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22
Q

what should be the “third step” in pharmacologic treatment of late life depression (if multiple 1st and 2nd step treatments are not effective or not indicated)

A

switch to amitriptyline or imipramine
or
combine an SSRI or SNRI with buproprion

23
Q

how does mortality rate compare between older adults that receive ECT for depression vs other treatments

A

older adults who receive ECT have a LOWER mortality rate compared to other depression treatments (like antidepressants)

24
Q

what combination of ECT and ADs has evidence for rapidly acting and effective treatment of late life depression

A

RUL ultrabrief pulse ECT (avg. 7 treatments of ECT) + venlafaxine

very good safety and tolerability when this combination is used

25
Q

list psychosocial interventions that have evidence for preventing or reducing depressive symptom burden in older adults according to the CCSMH guidelines

A
  1. interventions to reduce loneliness in older adults (i.e physical exercise programs)
  2. “social prescribing”–referral to local nonclinical services often provided by voluntary or community sector
  3. stepped care approach (including watchful waiting and CBT based bibliotherapy)
  4. increasing physical activity
  5. “instilling of hope and positive thinking”
  6. tai chi/yoga and other mind-body interventions
26
Q

in which older patients is ECT a first line treatment

A

older, depressed patients who are at high risk of poor outcomes–> those with suicidal ideation or intent, severe physical illness, or with psychotic features

27
Q

in which older patients should you consider ECT

A

treatment of older patients with severe unipolar depression who have previously had a good response to ECT and/or failed to respond to 1 or more adequate antidepressant trials plus psychotherapy

especially if health is deteriorating due to depression

28
Q

what psychotherapy may be considered in patients with cognitive impairment and executive dysfunction

A

problem solving therapy

29
Q

name two antidepressants that the CCSMH guidelines recommend considering as first line pharmacotherapy for acute episode of MDD in older adults

A

sertraline or duloxetine

(could also consider citalopram or escitalopram as few drug-drug interactions but this has more risk for QTc prolongation)

*ideally choose a med with lowest risk of anticholinergic side effects and drug-drug interactions as well as being safe in terms of cardiac comorbidity

30
Q

in which patients might a trial of rTMS be considered

A

older adults with unipolar depression who have failed to response to at least 1 adequate trial of AD

*not in those who have failed ECT or have seizures

31
Q

what is first line for treatment of depression in patients with parkinsons disease

A

SSRIs with SNRIs as alternative

32
Q

what is first line for treatment of post stroke depression

A

SSRIs (regardless if stroke is ischemic or hemorrhagic)

–SNRIs or mirtazapine are second line

–consider methylphenidate if APATHY is significant

33
Q

What is a scale that can be used instead of the geriatric depression scale (GDS) for those people with cognitive impairment

A

the Cornell Scale for Depression in Dementia

34
Q

how should geriatric patients with minor depression of less than 4 weeks duration be managed

A

supportive psychotherapy or psychosocial interventions

35
Q

when should pharmacotherapy be considered in geriatric patients with depression

A

after 4 weeks of symptoms after psychosocial interventions have been initiated

can also consider evidence based psychotherapy at this time

36
Q

how should mild or moderate late life depression be treated

A

pharmacotherapy, psychotherapy, or both

37
Q

how should severe late life depression be treated

A

combo of antidepressants and concurrent psychotherapy

38
Q

when should ECT be considered in late life depression

A

those with severe unipolar depression who have previously had a good response to ECT and/or failed to respond to 1 or more adequate trials of antidepressant trials plus psychotherapy

especially if health deteriorating rapidly due to depression

39
Q

in which patients is ECT a first line treatment

A

older, depressed patients who are at high risk of poor outcomes–> suicidal, severe physical illness, psychotic features

40
Q

how should an older patient with psychotic depression be managed

A

clinician should use clinical judgment deciding whether to try combo AD and AP first (now have placebo controlled trials reporting this is safe and effective treatment for psychotic depression)

ECT should be considered after 4-8 weeks of combo therapy fails, if poorly tolerated or if patient develops severe health consequences

41
Q

which patients should be referred to psychiatry services in late life

A

psychotic depression

bipolar disorder

depression with SI

those with depression with comorbid substance use d/o, severe MDD and depression with comorbid dementia may also benefit from referral

42
Q

is broad use of pharmacogenetic testing recommended in older adults

A

no

those with recurrent severe side effects to multiple ADs may benefit from testing to see if CYP450 metabolism is contributing

43
Q

how well to older adults respond to AD therapy compared to young adults

A

similar

44
Q

should ADs be used the same in those with multiple comorbidities and serious illnesses

A

yes–> should be used when indictaed

have similar efficacy rates in unwell elderly as they do in well elderly

AEs in patients with multiple medical comorbidities can be minimized by careful selection of drugs that are not likely to worsen or complicate patient specific medical problems

45
Q

list side effects of TCAs that are particularly worrisome for the elderly

A

postural hypotension/falls

cardiac conduction defects

anticholinergic effects (delirium, dry mouth, urinary retention, constipation)

46
Q

in the elderly, how should you monitor for hyponatremia when starting an AD

A

screen patient for history of hypoNa before starting the med

serum sodium should be done within 2-4 weeks of initiating SSRI/SNRIs

47
Q

list 3 types of ADs that have lower risk of hyponatremia

A

TCAs

bupropion

mirtazapine

48
Q

how should ADs be titrated in older adults

A

start at HALF the recommended dose for younger adults –> aim to reach an average dose within ONE MONTH if med is well tolerated at weekly reassessments

49
Q

why is fluoxetine not recommended for older adults

A

long half lfie

50
Q

why is paroxetine not recommended for older adults

A

higher anticholinergic risk

51
Q

how long should an older adult be treated with pharmacotherapy after successful remission of their first episode of depression

A

at least one year (and up to 2 years) with full therapeutic dose

52
Q

which older adult patients should continue AD maintenance treatment indefinitely (unless there is a contraindication)

A

those who have had 2 or more episodes

those who have had particularly severe or difficult to treat episodes or required ECT

53
Q

what is the first line for treatment of bipolar disorder in the elderly

A

lithium

4. Mood Disorders (17 decks)

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